Find comprehensive information on self-injurious behavior including clinical documentation, medical coding, and DSM-5 criteria. Learn about NSSI, self-harm, cutting, burning, and other forms of self-inflicted injury. This resource provides guidance for healthcare professionals on diagnosis, assessment, treatment, and intervention strategies for patients exhibiting self-injurious behavior. Explore resources related to mental health, behavioral health, and psychiatric coding for self-harm. Understand the difference between suicidal behavior and nonsuicidal self-injury for accurate documentation and billing.
Also known as
Other impulse-control disorders
Covers self-injurious behaviors not classified elsewhere.
Suicidal ideation
May be relevant if self-injury is associated with suicidal thoughts.
Personal history of self-harm
Documents past episodes of self-inflicted injury.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the self-injurious behavior associated with a known mental disorder?
When to use each related code
| Description |
|---|
| Self-harm without suicidal intent |
| Suicidal behavior disorder |
| Borderline personality disorder |
Coding self-harm without clarifying accidental vs. intentional nature leads to inaccurate data and potential claim issues. CDI crucial for specificity.
Minor self-harm may be undercoded if detailed documentation lacks. Comprehensive injury descriptions vital for accurate severity coding.
Coding self-harm without addressing underlying mental health disorders risks inaccurate severity and treatment. Thorough documentation needed.
Patient presents with self-injurious behavior (SIB), nonsuicidal self-injury (NSSI), characterized by deliberate self-harm without suicidal intent. The patient reports engaging in cutting behavior on their forearms, described as a coping mechanism for emotional distress and anxiety. Frequency of self-harm episodes varies, with increased incidence during periods of heightened stress. No suicidal ideation or plan reported at this time. Patient denies current use of drugs or alcohol. Mental status exam reveals affect congruent with reported mood, thought content focused on self-critical thoughts and feelings of inadequacy. Insight and judgment appear intact regarding the harmful nature of the SIB, but the patient expresses difficulty controlling the impulses. Differential diagnoses considered include borderline personality disorder, depression, anxiety disorder, and post-traumatic stress disorder. Assessment includes evaluation for past trauma, history of abuse, and family history of mental illness. Treatment plan includes referral for individual therapy focused on dialectical behavior therapy (DBT) skills training, cognitive behavioral therapy (CBT) techniques for managing emotional regulation, and safety planning to reduce self-harm behaviors. Patient education provided on coping strategies, stress management techniques, and resources for mental health support. Follow-up appointment scheduled to monitor progress and adjust treatment plan as needed. ICD-10 code F68.8 (other specified impulse control disorder) or Z91.51 (personal history of self-harm) may be applicable depending on the specific circumstances and presentation. CPT codes for evaluation and management services, psychotherapy, and psychological testing may be utilized for billing purposes, depending on the services rendered.